Provider Demographics
NPI:1609853365
Name:BOYSE, BRENT RUSSELL (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:RUSSELL
Last Name:BOYSE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6755 E SUPERSTITION SPRINGS BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4373
Mailing Address - Country:US
Mailing Address - Phone:480-830-5866
Mailing Address - Fax:480-807-0606
Practice Address - Street 1:6755 E SUPERSTITION SPRINGS BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4373
Practice Address - Country:US
Practice Address - Phone:480-830-5866
Practice Address - Fax:480-807-0606
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ53711223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0415850OtherBCBS
AZ1612346Medicaid
AZAZ0415850OtherBCBS